Transcript Nutrition for wound healing - Southlake Regional Health Centre

Nutrition for
Wound Healing
Puja Bansal, RD, CDE
10.31.12
SOS: Inter-professional Skin &
Wound Conference
Disclosures
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The contents of this presentation have been
developed solely by the presenter and the
research/literature searches that the
presenter has conducted
There are no disclosures to declare
At a glance…
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Wound
 Definitions
 Prevalence
 Burden
Biology of Wound Healing
Risk Factors to Wound Healing
 Nutritional Risk Factors
Role of Nutrition
Nutrition Assessment
Specific nutrients that can aid wound healing: macronutrients and
micronutrients
Other factors to consider when assessing nut’l needs for wounds
 Co-morbidities: Diabetes Mellitus (DM), Malnutrition (Obesity)
Case studies
Summary
Definition: Wound
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Injury to living tissue
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localized to the skin and/or underlying tissue,
usually over a bony prominence
Definition: Chronic wounds
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Requires >4-6 weeks to heal
Examples of wounds that may become chronic:
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Pressure ulcers
Post-op wounds
Wounds in people with DM
Ulcers on legs/feet; Venous leg ulcers
Extended burns
Stomas
Amputation wounds
Prevalence
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Woodbury & Houghton (2004 & 2005) estimated the
prevalence of pressure ulcers in Canada as:
25.1% acute care
29.9% non-acute care (LTC, nursing homes, etc.)
15.1% community care
26.2% mixed care (acute and non-acute)
26% overall in all health care institutions
Canadian data is lacking
Burden
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Chronic wounds particularly affect the elderly,
people with diabetes, the chronically ill and others at
risk
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Estimated cost to Canada’s Health Care system are
not well documented in the acute care setting
~$24,000 (CAD) per ulcer for 3 months of care in
complex care setting
~$27,500 (CAD) per ulcer to heal within the
community
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Increased hospital LOS
increased risk for mortality and morbidity
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Biology of Wound Healing
Wound Healing Risk factors
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Advanced age
Cognitive impairment /
altered sensory perception
Hypoxia, Infection/Sepsis
ICU patients, especially
vent dependent
Hyperglycemia / Diabetes
Inadequate perfusion /
oxygenation / circulation
Reduced mobility
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Multiple trauma/burns
Pre-operative illnesses/comorbidities
Some disease states 
hypermetabolism and
increase nutritional risk
 Increases energy
expenditure
 Energy sources:
i) Glycogen ii) Protein
Nutrition Related Risk Factors
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Unintentional weight loss > 10% x
3-6 months
Underweight / Low BMI <
18.5kg/m2
Obesity
Evidence of suboptimal intake results
in subcutaneous fat loss and/or
muscle wasting
 Protein, Calories, Fluid
Suboptimal glycemic control
Iron deficiency anemia
Vitamin/mineral
insufficiency/deficiency
Dehydration
Inability to feed independently
Role of Nutrition
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Macronutrients and micronutrients are involved in cellular,
structural and immune processes in all four phases of wound
healing
 Implicated in immune response set up by the body to reduce
infection
 Provide nutrients to build new tissue and optimize circulation
to wound site
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Objectives:
 Provide adequate calories
 Prevent protein-calorie malnutrition
 Promote wound healing
Nutritional Assessment
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Demographics: age,
gender
Diagnosis
PMHx: presence of other
conditions may affect
nutrient requirements
 Infection
 Malabsorption
 Chronic diseases –
diabetes, obesity, other
co-morbidities
Stage of wound
Weight history
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Current/past intake pattern
Evidence of malnutrition;
calculated BMI
Medication review
Biochemical test results
 serum levels of albumin,
pre-albumin, c-reactive
protein, total protein,
transferrin, cholesterol,
hemoglobin, vitamin
B12, folate, iron, etc.
Evaluation of estimated
nutritional requirements to
promote healing
Energy (Carbohydrates & Fat)
Carbohydrates and fats are sources of cellular
energy
 Glucose is preferred fuel for leukocytes,
fibroblasts, macrophages
 Promotes anabolism, nitrogen and collagen
synthesis and healing
 Adequate intake needed to prevent body from
using protein as energy source
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Function
30-35kcal/kg/d (AHRQ & EPUAP)
35-40kcal/kg/d (NPUAP for patients
underweight/losing wt)
Recommendations
Considerations
Dietary restrictions should be revised/liberalized
when limitations result in decreased po intake
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Protein
Structural component, growth and
maintenance of cells, enzymes
 Fluid and electrolyte balance
 Tissue maintenance and repair
 Collagen development
 Wound exudate contains proteins, including
albumin, losses can impact healing rate and
metabolic demand
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Function
Recommendations
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Caution
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1.2-1.5 g/kg (positive nitrogen balance)
 Up to 2 g/kg (severe wounds, great losses)
>2g/kg/d may have negative impacts on renal
and hepatic function; may increase risk of
dehydration
Fluid
Hydration impacts healing process and skin
turgor
 Contributes to good perfusion and
oxygenation of tissues
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Function
Recommendations
Caution
30-35ml/kg
30-40ml/kg (ASPEN)
 Additional fluids may be required with higher
protein intake/increased fluid losses
(evaporation from wounds, drainage; fever,
diarrhea, etc.), especially among elderly
Impaired renal/hepatic function
CHF
SIADH
Micronutrients:
Vitamins & Minerals
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As part of malnutrition, general deficiencies are
common (including zinc and vitamin C)
Supplements may be necessary and potentially
beneficial, if deficiency is suspected or present
A standard multivitamin with mineral supplement
plus add’l vitamin A, C, zinc may be appropriate for
most patients with wounds and micronutrient
deficiencies
Modification may be needed with renal or hepatic
insufficiency
Vitamin A
Role in protein synthesis
 Stimulates immune system
 Enhances epithelialization, wound strength
 Stimulates collagen formation/accumulation
 Can counteract effect of glucocorticosteroids on
wound healing by reducing inflammation
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Function
Recommendations
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Caution
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10,000 - 25,000 IU/d short terms x 10d
Toxicity concerns in high doses (daily doses of
50,000-100,000 IU/d x weeks to years in adults)
 Chronic renal failure
 Organ transplant, rheumatoid arthritis since
steroids used
 Pregnancy, women of child bearing age
Vitamin C
Essential co-factor for collagen synthesis and
subsequent cross-linking
 Enhances leukocytes and macrophages activity to
wound site
 Formation of new blood vessels (angiogenesis)
 Wound strength
 May prevent infection
 Increases Fe absorption
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Function
60-200mg/d (identified deficiency)
 Stage I & II: 100-200mg/d
 Stage III & IV (or smokers, highly stressed
(burns, surgery, infections), malnourished,
seriously injured): 1000-2000mg/d PO until healed
Recommendations
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Caution
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>60-100mg/d & <200mg/d in patients with renal
failure without dialysis, d/t risk of renal oxalate stone
formation
B-Complex Vitamins
Required for rebuilding of tissue
 Involved in energy production (converts
glucose, amino acids, fat)
 RBC formation
 Protein and amino acid metabolism
 Maintains immune function
 Formation of new cells/cell division
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Function
Recommendations
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Considerations
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None noted in literature
Deficiency of pyridoxine, pantothenic acid and
folic acid results in suppressed antibody formation
and leukocyte function, predisposing individuals
to infection and poor wound healing
 Thiamine deficiency (B1) may affect collage
synthesis
Zinc
Synthesis of collagen and protein
 Cell replication/tissue growth and wound strength
 Assists in immune function, metabolism of
macronutrients
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Function
Unless deficiency diagnosed, supplementation
is not indicated
 15mg/d elemental Zn (most MVI/min) adequate
 25-50mg/d elemental Zn x 10-14d if deficient
Recommendations
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Considerations
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Caution
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Zinc is primarily transported by albumin; absorption
decreased when serum albumin decreased
(malnutrition)
 Losses may occur from excess wound drainage
GI discomfort
 Excess can interfere/delay wound healing; copper
deficiency
 Toxicity levels ~100-300mg/d of long term use
Iron
Transports oxygen to wound site/tissues; therefore iron
(Hgb) deficiency can impair healing
 Assists with collagen production via hydroxylation of lysine
and proline
 Wound strength
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Function
General population: 8mg/d
 Females 19-5yo 18mg/d
 If iron deficient dx: Fe supplement warranted +
increase dietary Fe
Recommendations
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Considerations
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Caution
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If Hgb <100g/L – difficult to heal wounds
 Must distinguish b/w iron deficiency anemia vs. anemia of
chronic disease before considering supplementation
 Anemia could lead to hypovolemia and tissue hypoxia;
causing depressed inflammatory response, bacterial
infection, delayed wound healing
GI discomfort: nausea, constipation
 Avoid administering at same time zinc supplement given
as they compete for absorption
Amino Acid: Arginine
May be essential during acute stress
 Promotes protein synthesis
 Enhance immune function (nitric oxide
synthesis)
 Improves nitrogen balance
 Improve wound strength
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Function
No evidence-based guidelines for safe,
appropriate supplemental dose published
 17-24.8g/d free arginine (Gr II support)
Recommendations
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Considerations
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Caution
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Inconsistent results in human studies
Possible adverse effect secondary to
release of nitric oxide in critically ill patients;
can enhance inflammatory response and
sepsis
Amino Acid: Glutamine
Improve nitrogen balance
 Enhance immune function after major
surgery, trauma, brain injury
 Energy source for inflammatory cells
(fibroblasts, macrophages, epithelial cells
and lymphocytes) during healing
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Function
Recommendations
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0.57g/kg/d adult maximum dose
Considerations
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Inconsistent results in human studies
Summary of Nutrients involved
in Wound Healing
Injury
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Vitamin A – enhances early inflammatory response
Adequate protein intake – prevent prolonged
inflammatory phase
Haemostasis
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Inflammatory
Phase
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Vitamin C – enhances neutrophil migration and
lymphocyte transformation
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Vitamin C, B vitamins, Iron – collagen synthesis
Vitamin A – promotes epithelial cell differentiation
Zinc – DNA synthesis, cell division, protein synthesis
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Protein – promote wound remodeling
Proliferation
Phase
Remodeling
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Nutrition Guidelines: Summary
Stage I
Stage II
Stage III
Stage IV
Calories
(kcal/kg)
25-30
25-30
30-35
30-40
Protein
(g/kg)
1.0-1.2
1.2-1.5
1.5-2.0
1.5-2.0
Fluid
(ml/kg)
25-30
25-30
30-35
30-40
●MVI/mineral
●Vitamin C 250750mg/d
●Zinc 2550mg/d x 14d
●Same as St III
●If concomitant
use of
glucocorticoster
oids discuss w/
MRP re: 25,000
IU/d Vitamin A x
10d
Vitamin /
Mineral
Supplement
Consider if
intake is
inadequate
Recommend
Role of Nutrition Support
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Could consider if dietary intake remains
inadequate for prolonged period of time,
despite dietary modifications and use of oral
supplementation
Pre-surgery/injury, especially in malnourished
patients
Early EN intervention beneficial, within 2448h
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decreased LOS, risk of infection, improves wound
healing
Nutrition/Hydration-related
Blood Work
Albumin / Hepatic proteins
PreLow values reflect severity of illness and/or injury regardless of
albumin
protein status; “red flags” for potential for malnutrition
development
Albumin - not accurate marker of malnutrition in critical
care/acute care setting due to 21d half life
C
reactive
protein
Indicator
of inflammation; more educated interpretation of
serum albumin/pre-albumin
Total
Protein
Indicator
of total body protein stores; allows more educated
interpretation of long term protein levels
Nutrition/Hydration-related
Blood Work
Transferrin
More
sensitive indicator of protein stores than albumin d/t
8-10d half life
Preferable test to Prealbumin since more readily available
Fals3 low results if patients taking antibiotics
Hemoglobin
Anemia
Vitamin B12
Deficiency
common in >65y and can result in anemia
Folate
Deficiency
common in >65y and can result in anemia
Iron
Deficiency
can cause anemia, thereby reducing wound
is common in patients with pressure injuries;
impaired blood flow to injury and can thereby adversely
affect healing
healing
Nutrition/Hydration-related
Blood Work
Urea &
Creatinine
Dehydration
is a risk factor for skin breakdown and wound healing
BUN:Cr ratio may be used as an indicator of hydration status;
?accuracy in renal failure
High BUN + Normal/Low Cr  under-hydration
Also indicators of renal function; therefore must be aware of renal
status prior to making recommendations
Fasting
Blood
Glucose &
HbA1C
Screen
with all individuals that present with pressure ulcers
HbA1C > 7.0% assoc with sig increased risk for both microvascular
and macrovascular complication
Impaired glycemic control assoc with impaired wound healing,
increased complications
HypoMetabolic disorder, effects tissue integrity and regeneration that can
thyroidism adversely affect wound preventions/healing
Hypothyroidism and DM can coexist; therefore screening and
management necessary to optimize wound healing
Diabetes
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Poor BS control impairs wound healing and
increases risk of infection
Metabolic stress (wounds)  further increase
BS
Medical management + diet (increasing
LBM), activity, lifestyle education is
necessary to achieve optimal glycemic
control
Obese Patients
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BMI >30kg/m2: delayed wound healing
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Hypoventilation  decreased tissue oxygenation
Moisture and microorganisms in skin folds 
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reduced oxygen and nutrients perfusion from CV effects of
obesity
May impact LOS and morbidity
increased risk for infections
decrease skin integrity
Reduced vascularity in adipose tissue 
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induce venous HTN  vascular injury development
Obese Patients
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May be malnourished, have depleted LBM and
protein stores while maintaining adipose mass
Total weight irrelevant; functional compartmental
weight is important
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Energy requirements:
 50% adjBW = (current wt-IBW) x 0.5 + IBW OR
 Non-stressed pt: subtract 400-1000kcal from normal
requirements
 Mild-mod stress: BMR, using actual BW
 Severely stressed: add stress factor to BMR
Protein and Fluids: actual BW
Spinal Cord Injury (SCI)
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Weight adjustments to compensate for muscle
atrophy
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Energy requirements with pressure injuries:
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Long-term paraplegics: -4.5 to 7kg
Long-term tetraplegics: -7 to 9kg
Paraplegia: 25.9+/- 1.2kcal/kg BW/d
Tetraplegia: 24.3 +/- 1.1kcal/kg BW/d
Protein, Micronutrients, Fluids:
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Lack of evidence, therefore calculated as if for patients
without SCI
Case Studies
Profile I
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70 y.o. female, lives in a nursing home
Dx: CVA with left side deficits, unable to walk,
PMHx: HTN, mild dementia, GERD
BMI 31kg/m2, 15kg weight loss x 3 months
PO Intake: 25-50% meals provided at home, likes
commercial supplements; drinks less than 1-2
glasses of fluid/d
Meds: no multivitamin with mineral
Labs: Hgb 104, Hct 0.31, BUN 8.2, Cr 90, Na 137,
Alb 26,
Stage II leg ulcer
Profile II
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56 y.o. male
Dx: CVD, elective CABG
PMHx: Smoker, pre-surgery wt loss, BMI 17kg/m2,
HTN, previous CVA, DM2
Post-op: tube fed d/t post-op delerium and poor po
intake, dehissing sternum, worsening stage III
pressure wound to coccyx, dialysis q2d, unstable BS
(>14mmol/L) with sliding scale insulin
Labs: Alb 17, WBC 13, Hgb 86 (stable), BUN 11.0,
Cr 273,
Meds: No multivitamin with mineral
No fluid restriction ordered, however MRP wishes to
minimize fluid intake
Recommendations
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Provide adequate calories, protein, fluids
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May wish to add commercial supplements (ex.
2.0kcal/ml products)
Consider additional vitamins/mineral
supplementation, especially if a deficiency is
suspected
Liberalize diets to optimize nutrient intake
Include patients in development of care plan
Summary
Poor wound management
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Poor nutrition
Delayed wound healing
GOOD NUTRITION CAN HELP HEAL WOUNDS
Feed the body…heal the wound.
Thank you
References
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